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RISK FACTORS
Suicide is the culmination of a series of complex
interactions involving socio-cultural, bio-psychosocial,
and environmental components, often called risk
factors.
Suicide risk factors encompass a broad range of
circumstances, situations, and events that increase a
person’s susceptibility to suicide or suicidal behavior.
RISK FACTORS
Increase probability of negative outcomes
Exist on multiple levels
Develop over time
Co-exist
RISK FACTORS ASSOCIATED WITH ADOLESCENT
SUICIDE AMONG TEEN GIRLS INCLUDE:
Bio-psychosocial
• Psychiatric disorders/co-morbid psychiatric disorders
• Externalizing behaviors (i.e., delinquent and
aggressive behaviors)
• History of suicide attempt(s)
• Alcohol and substance abuse
• Family history of suicide
Socio-cultural
• Negative social interactions with family
• Barriers to mental health services
• Stressful life events, including loss of relationship
and violence
• Lack of social support or isolation
Environmental
• Access to firearms or other lethal means
• Suicide clusters
Additional Factors
• Sexual orientation/Youth who identify as GLBT
• Bullying
• Race
It is important to highlight that several of the risk
factors identified here can and do co-occur in many
suicidal adolescent girls. For example, research suggests
a higher probability of suicide among adolescent girls
who present with a combination of depression and
externalizing behaviors, such as delinquency and
aggression.
It is also important to note that risk factors do not
cause suicide. Simply stated, they increase one’s
potential for suicide and suicidal behaviors.
Of the identified risk factors, research supports the
strongest correlations for suicide among adolescent
girls with:
• Psychiatric disorders, namely depression
• Externalizing behaviors
• Alcohol and/or substance abuse
• Negative social exchanges with family
Not accounting for gender differences, there is also a
strong correlation between
• Adolescent suicide and prior suicide attempts.
Other risk factors may often co-occur with these five
variables, or they may exist as independent variables.
The extent of either in contributing to adolescent
suicide among teen girls has not been widely
researched.
BIO-PSYCHOSOCIAL RISK FACTORS
Psychiatric disorders
Several studies on adolescent suicide have found that,
among teenage girls who successfully committed
suicide, nearly 50percent had at least one psychiatric
disorder present at the time of death. Across the board,
the psychiatric disorder found to have the strongest
correlation between adolescent girls and suicide is
depression or other mood disorder, accounting for
more than 50 percent of suicide among this population.
The Diagnostic Statistical Manual of Mental Health
Disorders–Fourth Edition (DSM–IV) classifies mood
disorders as major depression, dysthymia, and bipolar
disorder. Of the three, major depressive disorder has
been found to represent the most significant risk factor
for adolescent girls and suicide. This finding is in no
way intended to suggest that teenage girls diagnosed or
presenting with symptoms of dysthymia or bipolar
disorder should not be considered “at-risk” for suicide.
Even in cases where depressive symptoms do not meet
the threshold for a clinical diagnosis of depression,
there still remains an increased risk for attempting
suicide. This would suggest that any teenage girl who
presents with symptoms of depression for more than
two to four weeks should be assessed, on some level,
for threat of harm to self.
Another finding worth noting here is a significant
association between depression and “romantic”
breakup as a risk factor for suicide, particularly among
teenage girls with lower levels of depression. Girls with
higher levels of depression are believed to be at
increased risk for suicide regardless of additional
stressors.
Other stressful events with significant findings for
increased suicide risk among teenage girls include:
violence or being physically assaulted and being
arrested or involved with juvenile justice.
Other psychiatric disorders found to have relevant
correlations for suicide and suicidal behaviors among
teenage girls, whether as comorbid psychiatric
disorders or as independent risk factors, include:
• Eating disorders, namely anorexia
• Anxiety
• Post-traumatic stress disorder (PTSD)
Further research is indicated to determine the extent to
which co-occurring psychiatric symptoms contribute to
suicide or suicide behaviors independent of depression
or with the presence of depressive symptoms.
Externalizing behaviors
When accounting for depression, externalizing or
disruptive behaviors, such as aggression, opposition,
and delinquency may stand alone as a “unique” risk
factor for suicide in teenage girls. However,
externalizing behaviors (and/or substance abuse) are
often present in combination with depression in more
than half of suicide completions involving teenage girls.
Externalizing behaviors are often viewed as
psychological problems directed outward toward other
persons or property, and may actually be an external
expression of depression. Consequently, the presence of
depression and externalizing behaviors in completed
suicides among teenage girls is not striking.
Alcohol and substance abuse
Similar to disruptive behaviors, a combination of
depression and substance abuse is associated with a
high percentage of suicides among teenage girls.
Adolescents abuse alcohol and drugs for numerous
reasons, including pressure from peers, to reduce stress,
and to feel grown up. However, teenage girls suffering
from depression or depressive symptoms may use
alcohol or other drugs to “self-medicate” or feel better,
even if just temporary. This combination of depression
and substance abuse, independent of other known risk
factors, increases the potential for suicide among
teenage girls.
The presence of alcohol or substance abuse should also
be viewed as a warning sign.
Family history of suicide
Having a close relative, such as a parent, sibling, aunt,
uncle, or grandparent, who committed suicide increases
the risk for (adolescent) suicide. Research is
inconclusive for gender differences.
In younger adolescent girls who experience negative
social interactions with family there is a higher
prevalence for suicidal “ideations” than in older
teenage girls from similar families. This is found to be
higher for Caucasian families.
Research is also inconclusive as to whether or not there
is a genetic predisposition to suicide or to a specific
psychiatric disorder, such as depression, known to have
a higher potential towards suicide. Further research in
this area is indicated. Findings do exist that suggest the
loss of a close friend can be a suicide risk factor,
especially in teenage girls with underlying depression.
Barriers to mental health services
One of the reasons suicide is difficult to prevent is the
presence of barriers to mental health services. These
barriers have often included disparities in the diagnosis
and treatment of depression among certain racial or
ethnic groups, including African Americans and other
persons of color.
History of suicide attempt(s)
Gender differences in prior suicide attempts have not
been widely studied and therefore data on adolescent
girls is limited. However, the overall risk remains
significant for adolescents, not accounting for gender
differences.
Studies have found that African Americans, including
adolescents/adolescent girls, are less likely to receive
treatment when suffering from depressive symptoms,
and are also less likely to be referred for psychotropic
medications used to treat depression. Further, African
American and other ethnic adolescents are less likely
than Caucasian adolescents to have health insurance,
which further diminishes their capacity to access health
care and mental health services.
A single prior adolescent suicide attempt can increase
the risk or future attempts by 25 to 50 percent. While a
prior suicide attempt cannot be changed, it is a more
visible risk factor, and can alert others to increased
suicide risk following stressful situations, such as a
break-up, act of violence, or court involvement.
SOCIO-CULTURAL FACTORS
Negative social interactions with family
Family dysfunction, in general, tends to be more
prevalent among adolescents with one or more
psychiatric disorders. For adolescents with
depression—known to be more prevalent among
adolescent girls than adolescent boys—the presence of
family dysfunction increases the risk for suicide or
suicidal behaviors, including ideations.
One pattern that seems to be consistent among
dysfunctional families is poor or reduced
communication among members, especially between
parent(s) and teenage children. However, it is not clear
just how much poor communication contributes to
suicide among teen girls.
Stressful life events, including loss of relationship and
violence
Adolescent girls who attempt suicide experience (or
perceive themselves to experience) more stressful events
than adolescent girls who do not attempt suicide. The
primary stressful life events include:
• Experiencing loss or termination of a relationship
• Being attacked or assaulted
• Being arrested or having other involvement with the
court system
Stressful life events such as these are more likely to
increase the risk for suicide when they co-occur with a
low level of depression.
Finally, suicide often follows a stressful event, such a
relationship break-up or other personal loss,
disciplinary action, or a court appearance. As with a
history of prior suicide attempts, the occurrence of
stressful life events should trigger an alert for
adolescent girls with underlying depression.
Lack of social support or isolation
Feeling isolated from others, including family and
peers, can be a risk factor for suicide among teenage
girls. As with several other factors, social isolation is
increasingly of concern in adolescent girls with
underlying depression or depressive symptoms.
Isolation may also present as a warning sign in suicidal
adolescent girls.
ENVIRONMENTAL FACTORS
Access to firearms or other lethal means
Having access to firearms and other lethal means of
suicide represent an increased risk for harm in the
presence of multiple risk factors, as opposed to being
the sole or primary risk factor for suicide. However,
given the impulsive nature of adolescence, guns and
other lethal means should be restricted.
Suicide clusters
The presence of a suicide cluster involving adolescents
is more likely to occur following an “initial public
suicide,” typically in a high school or community
setting. Research shows that, on average, teenage
suicide clusters will most typically result in the death of
three to seven teenagers over a period of three to nine
months. Adolescent suicide clusters have not been
widely studied and thus gender-specific data is limited.
ADDITIONAL FACTORS:
Sexual orientation/Youth who identify as GLBT
Adolescents who identify as lesbian, gay, bi-sexual,
and/or transgender (LGBT) have disproportionately
higher rates of suicidal behavior than non-LGBT
adolescents. In addition to the above factors, LGBT
adolescents are also linked to these additional risk
factors:
• Gender non-conformity
• Early sexual debut
An earlier study on sexual orientation and suicide risk
found that suicide attempts were twice as likely for
non-heterosexual adolescent girls than for heterosexual
girls. The same study found a correlation among sexual
orientation, suicidal behaviors, drug use, and patterns
of violence/victimization; however, the differences
between heterosexual and non-heterosexual girls was
non-specific or rather lacked significance. Further
research on sexual orientation and adolescent suicide is
indicated to determine whether or not there are
definitive factors associated with increased suicide risk
among non-heterosexual girls.
Bullying
Research on the bullying-suicide connection fluctuates
between conclusive and inconclusive findings that
bullying increases the risk for suicide in children and
adolescents. What is consistent throughout multiple
studies is that bullying harms children’s mental health
and may lead to depression and anxiety disorders.
Youth who are bullied also tend to have thoughts of
suicide, particularly those who are bullied beginning at
young ages. One report suggests that to “confirm a
definitive link [between bullying and suicide],
researchers would have to rule out the possibility that
some unknown factor makes certain children more
susceptible to both bullying and suicide.”
In the absence of a solid connection between the two
variables, adolescent girls who are bullied should be
assessed for known risk factors associated with suicide
to identify potential threats for harm.
Race as a Risk Factor
Overall, non-Hispanic White girls have the highest
rates for suicide, followed by American Indian and
Alaskan Natives. However, American Indian and
Alaskan Natives comprise a much smaller percentage
of the overall American population. For this
population, suicide happens to be the second leading
cause of death.
Subsequently, the adolescent suicide rates among
Native American and Alaskan Native adolescent girls
are alarming. Risk factors similar to those for the
overall (or general) adolescent female population have
been found to be associated with adolescent suicide for
Native American and Alaskan Native girls , but with
slightly higher rates for substance abuse and physical
and sexual abuse.
Conversely, non-Hispanic Blacks, Asian and Pacific
Islander, and Hispanic girls tend to experience lower
rates of suicide. However, the most current data
available through the Centers for Disease Control and
Prevention (CDC) suggest a rapid increase in teen
suicide among Hispanic girls over a brief period of
time. Data from other sources, including a recent study
out of Fordham University Graduate School of Social
Services, show higher rates of suicide attempts among
Hispanic adolescent girls.
The Fordham study suggests a lack of mutuality in the
mother/daughter relationship as a leading risk factor
for suicide among Hispanic teenage girls. In the study,
Hispanic teenage girls who perceived their mothers
were interested, involved, respectful, patient, receptive,
and understanding were less likely to attempt suicide.
Another risk factor found to be specifically associated
with this population included poor coping and
problem-solving skills.